December, 2010 - SUPPORT Summary of a systematic review | print this article |

Does midwife-led care improve the delivery of care to women during and after pregnancy?

Midwives are the primary providers of care for childbearing women around the world. In midwife-led care, midwives are the lead profes-sionals in the planning, organisation and delivery of care given to women from the initial booking to the postnatal period. Non-midwife models of care include obstetrician-provided care; family physician-provided care; and shared models of care, in which responsibility for the organisation and delivery of care is shared between different health professionals.

 

Key messages

  • Compared to other models of care, midwife-led care:

- Leads to fewer antenatal hospitalisations and instrumental vaginal deliveries
- Decreases the use of pain killers during labour
- Leads to more spontaneous vaginal births, and
- Probably has little or no effect on numbers of foetal and neonatal deaths, augmentation or induction of labour, caesarean sections, and postpartum haemorrhage

  • The studies included in the review were conducted in high-income countries. Factors that need to be considered when assessing the transferability of the findings to a particular LMIC setting include the availability and training of midwives, as well as women’s access to other models of healthcare for pregnant mothers

Background

In most low- and middle-income countries, midwives are the primary providers of care for childbearing women. In midwife-led care, midwives are the lead professionals in the planning, organisation, and delivery of care given to women from initial antenatal bookings through to the postnatal period. Referrals to specialist obstetric care are provided as needed. The midwife-led model of care is woman-centred and based on the premise that pregnancy and birth are normal life events. Other models of care include obstetrician-provided care; family physician-provided care, including referral to specialist obstetric care as needed; and shared models of care, where responsibility for the organisation and delivery of care, from initial bookings through to the postnatal period, is shared between different health professionals.

This summary is based on a Cochrane review published in 2008 by Hatem and colleagues which aimed to synthesise available information on the effects of midwife-led care.



About the systematic review underlying this summary

Review Objectives: To compare midwife-led care with other models of care for childbearing women and their infants.
/ What the review authors searched for What the review authors found
Interventions Randomised controlled trials comparing midwife-led care to other models of care
11 randomised controlled trials
Participants

Pregnant women, classified as being at low or mixed risk of complications

12,276 pregnant women recruited from both commu-nity and hospital settings
Settings Not pre-specified

Australia (5 studies), Canada (1 study), United Kingdom (UK) (5 studies)

Outcomes

Antenatal, labour, delivery and immediate postpartum, neonatal, and maternal postpartum outcomes

Antenatal, labour, delivery and immediate postpartum, neonatal, and maternal postpartum outcomes

Date of most recent search: January 2008
Limitations: A good quality systematic review with only minor limitations

Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. See in Cochrane Library

Summary of findings

The review summarised 11 randomised controlled trials (RCTs) involving 12,276 women, conducted in high-income countries.

 

1) Antenatal outcomes

Five randomised trials reported data on antenatal hospitalisation, nine reported on foetal loss before 24 weeks, and 10 on overall foetal loss and neonatal death. A synthesis of these trials shows that:

  • Midwife-led care leads to fewer foetal deaths before 24 weeks of gestation and fewer antenatal hospitalisations than other models of care
  • There is little or no difference in overall foetal and neonatal deaths between midwife-led care and other models of care

Antenatal outcomes

Patient or population: Pregnant women at risks of complications which range from low to high
Settings
: Tertiary and community hospitals in Australia, Canada, and UK
Intervention
: Midwife-led care
Comparison
: Other models of care
Outcomes Comparative risks*
Relative effect
(95% CI)
Number of Participants
(studies)
Quality of the evidence
(GRADE)
Other models of care
Midwife-led care
Antenatal hospitalisation
263 per 1,000

237 per 1,000
(213 to 260)

RR 0.90
(0.81,0.99)

4,337
(5)

Foetal loss before 24 weeks
45 per 1,000

36 per 1,000
(29 to 44)

RR 0.79
(0.65,0.97)

9,890
(8)


Overall foetal loss and neonatal death 45 per 1,000

37 per 1,000
(31 to 45)

RR 0.83
(0.70,1.00)

11,806
(10)

CI: Confidence interval   RR: Risk ratio   GRADE: GRADE Working Group grades of evidence (see above and last page)
*Illustrative comparative risks. The assumed risk WITHOUT the intervention is based on the control group risk in the review. The corresponding risk WITH the intervention (and it’s 95% confidence interval) are based on the overall relative effect (and its 95% confidence interval).


2) Labour outcomes

Ten randomised controlled trials reported data on augmentation or induction of labour, five reported on use of intra-partum analgesia or anaesthesia, and 10 on induction of labour. These results, pooled together, show that:

  •  Midwife-led care decreases the use of analgesia or anaesthesia during labour
  •  Midwife-led care probably leads to little or no difference in the augmentation or induction of labour, compared to other models of care

Labour outcomes

Patient or population: Pregnant women at risks of complications which range from low to high
Settings
: Tertiary and community hospitals in Australia, Canada, and UK
Intervention
: Midwife-led care
Comparison
: Other models of care
Outcomes Comparative risks*
Relative effect
(95% CI)
Number of Participants
(studies)
Quality of the evidence
(GRADE)
Other models of care

Midwife-led care

Augmentation of labour

292 per 1,000

269 per 1,000
(237 to 307)

RR 0.92
(0.81,1.05)

11,709
(10)


No intrapartum analgesia
167 per 1,000

194 per 1,000
(175 to 215)

RR 1.16
(1.05,1.29)

7,039
(5)


Induction of labour 194 per 1,000

182 per 1,000
(161 to 206)

RR 0.94
(0.83,1.06)

11,711
(10)

CI: Confidence interval   RR: Risk ratio   GRADE: GRADE Working Group grades of evidence (see above and last page)
*Illustrative comparative risks. The assumed risk WITHOUT the intervention is based on the control group risk in the review. The corresponding risk WITH the intervention (and it’s 95% confidence interval) are based on the overall relative effect (and its 95% confidence interval).

 

3) Delivery and immediate postpartum outcomes

Twelve RCTs reported data on caesarean sections, nine on spontaneous vaginal delivery, and seven on postpartum haemorrhage. Combining these results shows that compared to other models of care:

  •  A midwife-led model of care leads to little or no difference in the incidence of caesarean sections or postpartum haemorrhage
  •  Midwife-led care leads to more spontaneous vaginal births and less instrumental vaginal delivery than other models of care

Delivery and immediate postpartum outcomes

Patient or population: Pregnant women at risks of complications which range from low to high
Settings
: Tertiary and community hospitals in Australia, Canada, and UK
Intervention
:Midwife-led care
Comparison
: Other models of care
Outcomes Comparative risks*
Relative effect
(95% CI)
Number of Participants
(studies)
Quality of the evidence
(GRADE)
Other models of care
Midwife-led care
Caesarean birth
124 per 1,000

119 per 1,000
(108 to 131)

RR 0.96
(0.87, 1.06)

11,897
(11)


Spontaneous vaginal birth
710 per 1,000

738 per 1,000
(724 to 753)

RR 1.04
(1.02, 1.06)

10,926
(9)


Postpartum haemorrhage 50 per 1,000

51 per 1,000
(42 to 62)

RR 1.02
(0.84, 1.23)

8,454
(7)

Instrumental delivery 125 per 1,000

108 per 1,000
(97 to 120)

RR 0.86
( 0.78, 0.96 )

11,724
(10)

CI: Confidence interval   RR: Risk ratio   GRADE: GRADE Working Group grades of evidence (see above and last page)
*Illustrative comparative risks. The assumed risk WITHOUT the intervention is based on the control group risk in the review. The corresponding risk WITH the intervention (and it’s 95% confidence interval) are based on the overall relative effect (and its 95% confidence interval).

 

4) Neonatal and postpartum outcomes

RCTs that reported neonatal and maternal postpartum outcomes show that:

  • Midwife-led care leads to little or no difference in the incidence of low birthweight and preterm birth, compared to other models of care

Neonatal and maternal postpartum outcomes

Patient or population: Pregnant women at risks of complications which range from low to high
Settings
: UK, Australia
Intervention
: Midwife-led care
Comparison
: Other models of care
Outcomes Comparative risks*
Relative effect
(95% CI)
Number of Participants
(studies)
Quality of the evidence
(GRADE)
Other models of care
Midwife-led care
Low birthweight
63 per 1,000

62 per 1,000
(52 to 74)

RR 0.99
(0.83,1.17)

8,009
(5)


Preterm birth
68 per 1,000

59 per 1,000
(50 to 71)

RR 0.87
(0.73,1.04)

7,516
(5)


CI: Confidence interval   RR: Risk ratio   GRADE: GRADE Working Group grades of evidence (see above and last page)
*Illustrative comparative risks. The assumed risk WITHOUT the intervention is based on the control group risk in the review. The corresponding risk WITH the intervention (and it’s 95% confidence interval) are based on the overall relative effect (and its 95% confidence interval).

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
  • The trials included in the review were conducted in high-income countries. However, midwives are the primary providers of antenatal and postpartum care in most low- and middle-income countries (LMICs). The measured effects may be transferable to LMIC settings.
  • When assessing the transferability of these findings to LMIC settings, the following factors should be considered:

- The availability and training of midwives
- Accessibility to other models of healthcare for childbearing women
- Cost implications of other models of care compared to midwife-led care
- Local epidemiology of maternal and perinatal mortality

    EQUITY
    • There was no information in the included studies regarding the differential effects of the interventions on resource-disadvantaged populations.
    • Given the scarcity of obstetricians and family physicians serving disadvantaged populations in LMICs, the use of midwife-led care has the potential to reduce inequalities in access to antenatal and postpartum care, provided the midwives are recruited, trained, supported and retained in under-served communities. Consideration should be given to incentives and regulations encouraging this.
    ECONOMIC CONSIDERATIONS
    • Five studies presented cost data using different economic evaluation methods. Evidence from these studies suggests that the use of midwife-led care may reduce costs when compared to medical-led care.
    • Midwife-led care is cost effective and produces comparable outcomes.
      If there are limited resources, midwives provide an affordable alternative to medical care with equivalent outcomes.
    MONITORING & EVALUATION
    • No evidence from low- and middle-income countries was identified in this review.
    • In light of the paucity of data on the applicability and efficiency of using midwives to substitute for medical doctors in LMICs, their use should be pilot tested and their impacts and costs rigorously monitored and evaluated.

    *Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

    Additional information

    Related literature

    Muthu V, Fischbacher C. Free-standing midwife-led maternity units: a safe and effective alternative to hospital delivery for low-risk women?. Evidence-Based Healthcare and Public Health.2004;8:325-331.

     

    Walsh D, Downe SM. Outcomes of free-standing, midwife-led birth centers: a structured review. Birth 2004;31:222-29.

     

    Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. Cochrane Database Syst Rev 2005 Jan 25;(1):CD000012.

     

    Ciliska D, Hayward S, Thomas H, Mitchell A, Dobbins M, Underwood J, Rafael A, Martin E. A systematic overview of the effectiveness of home visiting as a delivery strategy for public health nursing interventions. Can J Public Health 1996; 87:193-98.

     

    Kendrick D, Elkan R, Hewitt M, Dewey M, Blair M, Robinson J, Williams D, Brummell K. Does home visiting improve parenting and the quality of the home environment? A systematic review and meta analysis. Arch Dis Child 2000;82:443-51.

     

    McNaughton DB. Nurse home visits to maternal-child clients: a review of intervention research. Public Health Nurs 2004;21:207-19.

     

    This summary was prepared by

    Charles Shey Wiysonge, School of Child and Adolescent Health, University of Cape Town, South Africa; Charles Okwundu, South African Cochrane Centre; Cape Town, South Africa

     

    Conflict of interest

    None. For details, see: Conflicts of Interest

     

    Acknowledgements

    This summary has been peer reviewed by: Jane Sandall, UK; Eugene J Kongnyuy, UK; Patricia McNiven, Canada; Eileen Hutton, Canada; Tracey Pérez Koehlmoos, Bangladesh.

     

    This summary should be cited as

    Wiysonge CS, Okwundu CI. Does midwife-led care improve the delivery of care to women during and after pregnancy? A SUPPORT Summary of a systematic review. December 2010.

     

    This summary was prepared with additional support from:

    University of Cape Town (UCT), South Africa. UCT aspires to become a premier academic meeting point between South Africa, the rest of Africa, and the world. Taking advantage of expanding global networks and our distinct vantage point in Africa, we are committed, through innovative research and scholarship, to grapple with the key issues of our natural and social worlds. www.uct.ac.za

    The South African Cochrane Centre. The only centre of the international Cochrane Collaboration in Africa, aims to ensure that health care decision making in Africa is informed by high quality, timely and relevant research evidence. www.mrc.ac.za/cochrane/cochrane.htm



    Comments